Adverse effect of the financial crisis in Greece on perinatal factors

Adverse effect of the financial crisis in Greece on perinatal factors Abstract Background Starting in 2008 recession affected many European countries and especially Greece. Previous studies have reported increases in low birth weight, preterm birth and stillbirth rates in Greece during early crisis. In our study we used data on births from 1980 to 2014 that allowed us to distinguish recent changes, which could possibly be attributed to the financial crisis, from long term trends, and controlled for maternal age and country of origin as potential confounders. Our study covered a longer period (up to 2014) than what has been studied before and looked separately at the effect of early and established crisis. Methods We used national vital statistics data from 1980 to 2014. We performed age standardization and calculated age standardized rates and standardized rate ratios (SRRs) for perinatal factors for three time periods (pre-crisis, early crisis and established crisis) for Greek and non-Greek women. Results We found an increase in low birth weight deliveries independent of maternal age and origin and an increased stillbirth rate in Greek women younger than 25 in early (RR = 1.42 95%CI: 1.12–1.80) and established crisis periods (RR = 1.36 95%CI: 1.07–1.72) compared with pre-crisis. Non-Greek women have also been affected, with their advantage regarding birth outcomes becoming less profound in the established crisis period (low birth weight: established crisis SRR = 0.84 95%CI: 0.82–0.87, pre-crisis SRR = 0.79 95% CI: 0.76– 0.81). Conclusions The financial crisis has possibly adversely affected perinatal factors in Greece. Our results highlight the need of appropriate public health interventions and family support policies, especially for younger people, unemployed and immigrants. Introduction Financial crises have adverse effects on population health.1 Poor economic conditions and high unemployment rates have been associated with increased infant mortality rates, greater unmet healthcare needs, increase in obstetric trauma.1 After 2008 the Greek economy has entered a phase of severe recession, characterized by high unemployment and reduction of the gross domestic product (GDP).2 From 2008 to 2014 GDP per capita was reduced by 32% (Supplementary figure A1). Consecutive austerity measures, including cuts to public health spending, have been implemented.3 The consequences of the crisis on population health and especially on perinatal factors have not been yet thoroughly investigated. A rise in infant mortality4 along with an increase in the proportion of low birth weight infants3 and stillbirth rate4 have been found in Greece after the beginning of the economic crisis. A decrease in birth rates and an increase in the mean maternal age have also been observed.5 Nevertheless, the studies that have been carried out until now cover only a short period after the beginning of the crisis, while recent changes are usually not looked at in the light of long term trends. Furthermore, possible confounding factors have not been investigated. The aim of our study was to investigate recent changes in perinatal parameters in the framework of long term trends (since 1980), in order to distinguish possible effects of the economic crisis from long-standing developments. Moreover, our study covered a longer period (up to 2014) than what has been studied before using nationwide data, and looked separately at the effect of early (2008–10) and established crisis (2011–14). Finally, in our analysis we controlled for maternal age and country of origin, which are potential confounders of the apparent association between perinatal factors and the period of the financial crisis. Methods We used national statistical data from 1980 to 2014 for live births, maternal age at birth, preterm and low birth weight deliveries, infant mortality and stillbirth rate.6 Data on births by maternal age for the year 2000 are not presented due to an error in the dataset available. Furthermore, we used national statistical data from 2004 to 2014 for the above perinatal parameters by maternal age and maternal country of origin (Greek/non-Greek)6 and data for infant mortality by infant citizenship (country) for the years that these were available (2013–15).6 Infant mortality is defined as the ratio of deaths in children under 1 year of age by the total number of live births in the same period7 and stillbirth rate as the ratio of deaths that occur before birth and after 28 completed weeks of gestation by the number of live births8; low birth weight is weight at birth <2500 g and very low birth weight <1500 g.7 Preterm birth is defined as live birth before 37 completed weeks of gestation and very preterm before 32 weeks.9 Countries were grouped using the United Nations human development index (HDI) 2014.10 All data are aggregate and were obtained from the Hellenic Statistical Authority.6 In order to study recent changes in perinatal parameters and the possible effects of the financial crisis, we defined three periods: pre-crisis (2004–07), early crisis (2008–10) and established crisis (2011–14). We performed age standardization using the direct method to compare perinatal factors in the three study periods and between Greek and non-Greek mothers. The standard population was births by maternal age in the years 2000–04 (Supplementary table A1). Standardized rate ratios (SRRs) and 95% CIs were calculated with the ‘distrate’ Stata module.11 We used Apache Open Office Calc v.4.1.1 for data process and simple calculations, and Stata 11.0 to calculate risk ratios (RRs) and 95% CIs. Results Long-term trends Low birth weight rate has been increasing since 1980 with a stabilization from 2000 to 2008 and a further increase in the early crisis period (2008–10). In the period of established crisis (2011–14), low birth weight rate is decreasing towards 2008 levels. Very low birth weight rate (<1500 g) remains constant throughout the study period (figure 1a). Figure 1 View largeDownload slide Trends in perinatal factors, Greece, 1980–2014. (a) Low birth weight and very low birth weight, percent (%) of live births. (b) Preterm births and very preterm births, percent (%) of live births. (c) Stillbirths per 1000 live births. (d) Births to women 35-years old and older, percent (%) of live births. Data source: ELSTAT6 Figure 1 View largeDownload slide Trends in perinatal factors, Greece, 1980–2014. (a) Low birth weight and very low birth weight, percent (%) of live births. (b) Preterm births and very preterm births, percent (%) of live births. (c) Stillbirths per 1000 live births. (d) Births to women 35-years old and older, percent (%) of live births. Data source: ELSTAT6 Preterm birth rate presents a radical increase since 1991, while it tends to stabilize in the established crisis period. The increase is due to births after the 32nd week of gestation, as very preterm birth rate (before 32 weeks) remain stable throughout the study period (figure 1b). Infant mortality has been constantly declining from 1980 to 2008 (historic low). From 2008 onwards (period of early and established crisis), it tends to stabilize in levels somewhat higher than 2008 (Supplementary figure A2a). After constant decrease since 1980, stillbirth rate shows an increase in the years of early crisis followed by a slight decrease thereafter, remaining, though, higher than in 2008 (figure 1c). The proportion of births to women 35-years old and older has been increasing in the last 30 years; reaching 27% of all births in 2014 (figure 1d). Births to women 35-years old and older represent 26% of total births in 2011–14, while in 2004–07 they represented 19% of total births (figure 1d). The proportion of births to non–Greek women has increased from 2004 to 2007, remained stable during early crisis and decreased in the period of established crisis (Supplementary figure A2b). Of note, the crude birth rate (births per 1000 population) in Greece has been decreasing in the years of the financial crisis (after 2008), following an 8-year period of increase, reaching historic low levels in 2014 (Supplementary figure A1). Low birth weight, preterm births and stillbirths by maternal age and origin Risk for low birth weight and preterm birth is significantly increased in early and established crisis periods compared with pre-crisis after age standardization, both in Greek and non-Greek mothers (table 1). Table 1 Comparison of age standardized rates of low birth weight, preterm birth and stillbirth by maternal origin in the three study periods n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 a ASR, age standardized rate (per 100 live births), using the direct standardization method. b SRR, age standardized rate ratio. Table 1 Comparison of age standardized rates of low birth weight, preterm birth and stillbirth by maternal origin in the three study periods n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 a ASR, age standardized rate (per 100 live births), using the direct standardization method. b SRR, age standardized rate ratio. When examined by age group and citizenship, risk of low birth weight and preterm birth is significantly increased in the periods of early and established crisis in comparison to the pre-crisis period for women of both Greek and non-Greek origin and for all age groups, with the exception of low birth weight in women aged 35–39 (Supplementary table A2). Low birth weight and preterm birth rates after standardizing for age are consistently lower in women of non-Greek origin than in women from Greece and this holds for all three study periods (table 2). Table 2 Comparison of age standardized low birth weight, preterm birth and stillbirth rate, between Greek and non-Greek women, in the three study periods Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 a SRR, age standardized rate ratio. For numbers of infants and age standardized rates (see table 1). Table 2 Comparison of age standardized low birth weight, preterm birth and stillbirth rate, between Greek and non-Greek women, in the three study periods Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 a SRR, age standardized rate ratio. For numbers of infants and age standardized rates (see table 1). Risk of stillbirth after standardizing for age doesn’t show any significant change in the early and the established crisis periods (Supplementary table 1). In contrast, risk of stillbirth in Greek women younger than 25-years old is significantly higher in the years of the financial crisis in comparison to the pre-crisis period (Table A2). Contrary to the association found for low birth weight and prematurity, risk of stillbirth is higher in mothers of non-Greek origin than in mothers from Greece, in all three study periods after standardizing for age (table 2). Stillbirth and infant mortality rates show a gradient when examined by HDI group of countries, with the risk of stillbirth being two times higher in women from countries with a medium and low HDI compared with Greek women (table 3). Table 3 RR of stillbirth and infant mortality by citizenship; countries categorized by 2014 HDI Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 a Stillbirth rate: stillbirths per 1000 live births. b Infant mortality: infant deaths per 1000 live births. Table 3 RR of stillbirth and infant mortality by citizenship; countries categorized by 2014 HDI Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 a Stillbirth rate: stillbirths per 1000 live births. b Infant mortality: infant deaths per 1000 live births. Discussion An increase in low birth weight and preterm birth rates is observed during the financial crisis, in excess to a pre-existing continuing trend since 1990. The increase in low birth weight and preterm birth rates during the financial crisis cannot be explained by maternal age and origin, as it is present after age standardization for both Greek and non-Greek mothers in early crisis and established crisis periods. In contrast, the increase in stillbirths can be attributed to increased maternal age, as after age standardization there is no significant difference between pre-crisis period and early or established crisis periods. The differences in low birth weight, preterm birth and stillbirth rates between Greek and non-Greek women cannot be explained only by the difference in age distribution in the two population groups, as they are persistent and significant after age standardization. Preterm births and low birth weight The increasing trend in preterm births since 1990 is observed in other developed countries as well,12 while in many European countries in the same period the preterm birth rate for singleton births has remained stable.13 The increase in preterm birth rates has been attributed to a number of factors, like advances in foetal medicine that allow the survival of babies that would be stillborn,12 changing obstetric practice and excessive medical interventions (caesarean sections, labour induction) in the USA,14,15 Spain16 and Greece17 and the registration of extremely and very preterm births.12 Smoking is a known risk factor for preterm births and low birth weight. In the period 2005–15, smoking prevalence in women in Greece has declined by 0.6% annually,18 indicating that the observed increase in preterm birth and low birth weight rates is probably not confounded by maternal smoking. The recent global financial crisis has been associated with increases in low birth weight rates in Iceland,19 Portugal,20 Spain21 and in the USA.22 Socioeconomic factors that tend to deteriorate during a recession, like unemployment and low income, have been associated with low birth weight.23 Furthermore, socioeconomically disadvantaged women have been found to be more vulnerable to the effects of the financial crisis.19,21 We did not have information on the socioeconomic status of the mothers, to directly assess differential impact of the financial crisis on different social groups. Nevertheless, we observed an increase in low birth weight rates across most age groups during the crisis compared with the pre-crisis period, but not for women 35–39. This age group could be less exposed to adverse socioeconomic conditions, as unemployment resulting from the recession has disproportionally affected people younger than 30.6 We found that women of non-Greek origin have lower preterm birth and low birth weight rates and a lower relative risk for low birth weight and preterm births after controlling for maternal age, compared with Greek women. Better birth outcomes in migrant women, despite their lower socioeconomic status, have been observed in studies in Europe24 and the USA,25 while in the UK millennium cohort study immigrants had an increased risk for low birth weight, explained by socioeconomic factors and differences in antenatal care.26, In previous studies in Greece the advantage in favour of non-Greek women in terms of birth weight and prematurity has also been observed.27,28 Healthy immigrant effect and the adherence to healthier behaviours and diet observed in their countries of origin have been proposed as possible explanations for the observed difference in birth outcomes.28 Migrant women in Greece have a lower rate of twin deliveries in comparison to Greek women, a factor that may also contribute to the lower preterm birth and low birth weight rates observed for non-Greek women.29 Another contributing factor could be the mode of delivery, as differences in caesarean section rates between Greek and non-Greek women have been reported in previous studies.27,30 In the established crisis period, the advantage of non-Greek women regarding birth outcomes is becoming less profound (table 2). This may reflect an effect of the recession on immigrant population or it could be attributed to the fact that many immigrants have left the country since the beginning of the financial crisis (the population of non-Greek women 15–50-years old has been reduced by 11% in the years 2009–14)6 and those who stayed are possibly more similar to the native population (people who have lived in Greece for many years, second generation etc.). In a similar study in Portugal, the increase of low birth weight rates in migrant women has been interpreted as loss of the healthy immigrant effect in the context of a worse impact of the economic crisis in immigrants.20 Stillbirths—infant mortality We found evidence that older maternal age in 2008–12 is a key contributing factor to the observed increase in stillbirths during this period. After age standardization, the differences in stillbirth risk between pre-crisis period and early and established crisis periods are no longer significant. Maternal age older than 35 years has been associated with an increase of 65% in the odds of stillbirth31 in high-income countries in a meta-analysis using studies performed between 1998 and 2008 and financial crises have been associated with postponement of fertility,32 which might be a possible explanation of our findings. Of interest is the significant increase we found in the risk of stillbirth in the years of the crisis for Greek women younger than 25 years. Stillbirths are associated with poor access to healthcare and inadequate antenatal care.33 The crisis has lead to an increase in unemployment, particularly among young women6 and barriers to access to healthcare,2 which could be associated with the observed increase in stillbirths. Furthermore, younger mothers tend to have a lower educational level compared with older ones, which is an indicator of socioeconomic status; e.g. in the study period (2004–14) 33.6% of mothers aged <25 years had primary education or less compared with 7.6% of mothers 25-years old or more.6 Unemployment34 and low socioeconomic status31,35 have also been described as risk factors for stillbirth. The increased stillbirth rate observed in women of non-Greek origin shown by our data is consistent with other studies from European countries23,35–37 and has been attributed to inadequate antenatal and perinatal care and communication difficulties.36,37 Access barriers to antenatal services and communication barriers could explain the above findings of our study. Moreover, we observed a clear gradient in stillbirth risk by HDI group of countries of origin. Other studies have shown that women of African origin are the most disadvantaged in terms of stillbirth,23,35,37 but the factors driving this difference in the case of Greece need to be investigated. Infant mortality is an indicator associated with living conditions and socioeconomic status.38 We found higher infant mortality in women originating from countries with medium and low HDI, probably reflecting that these populations are the most disadvantaged among immigrants. Conclusions In our study we used data on births from 1980 to 2014 that allowed us to distinguish recent changes, which could possibly be attributed to the financial crisis, from long term trends. Moreover, our study covered a longer period (up to 2014) than what has been studied before using nationwide data, and looked separately at the effect of early and established crisis. Finally, in our analysis we controlled for maternal age and country of origin, which are potential confounders of the apparent association between perinatal factors and the period of the financial crisis. An important limitation of our study is the use of routinely collected aggregate data on births and our investigation was restricted to the impact of the factors for which data was available. Although in our study we used information regarding an extended period of time, the data used are comparable. Complete registration of births and stillbirths has been well established in Greece in the whole study period, and national data on the variables we used (maternal age, birth weight, gestational age) have been consistently collected.39 In conclusion, we showed that there is an increase in low birth weight and preterm deliveries associated with the financial crisis in Greece, that cannot be explained by maternal age and country of origin, while the effect of the crisis on stillbirths can be explained by changes in the distribution of these parameters, with the notable exception of the increase in stillbirth rate among Greek women younger than 25-years old. We also showed that rates of low birth weight and preterm deliveries are more favourable in non-Greek women, an advantage that became less profound in the period of established crisis. Public health policies ensuring access to adequate perinatal care for all women, including immigrants, unemployed and uninsured, and targeted social support interventions for women of reproductive age and young couples are needed in order to support families and alleviate the negative effects of the financial recession. These measures could include: increased funding of public prenatal and maternity care; the reintroduction of family benefits for all employees (cut with the austerity measures in 2012); policies facilitating the entry into the labour market for younger people; the employment of intercultural mediators which could help immigrants overcome communication difficulties. Analytical studies investigating more risk factors, including individual-level socioeconomic status indicators, are needed in order to establish causal associations and pathways between the recession and adverse effects on perinatal factors, and determine the factors lying behind the differences in birth outcomes between women of Greek and non-Greek origin, in order to design and implement more targeted interventions. Conflicts of interest: None declared. Acknowledgements The authors would like to thank the Hellenic Statistical Authority (ELSTAT) for providing the data. Key points The financial crisis in Greece contributed to an increase in low birth weight and preterm deliveries independently of maternal age and country of origin. The effect of the financial crisis on stillbirths can be explained by changes in maternal age and origin distribution, with the notable exception of the increase in stillbirth rate among Greek women younger than 25-years old. Rates of low birth weight and preterm deliveries are more favourable in non-Greek women, an advantage that became less profound in the period of established crisis. Our results highlight the need for appropriate public health interventions and family support policies, especially for younger people, unemployed and immigrants. References 1 van Gool K , Pearson M . Health, Austerity and Economic Crisis: Assessing the Short-term Impact in OECD countries. OECD Health Working Papers, OECD Publishing; 2014 . Report No.: 76 Available at: http://dx.doi.org/10.1787/5jxx71lt1zg6-en (23 March 2016, date last accessed) 2 Zavras D , Zavras AI , Kyriopoulos I-I , Kyriopoulos J . Economic crisis, austerity and unmet healthcare needs: the case of Greece . BMC Health Serv Res 2016 ; 16 : 309 . Google Scholar Crossref Search ADS PubMed 3 Kentikelenis A , Karanikolos M , Reeves A , et al. Greece’s health crisis: from austerity to denialism . Lancet 2014 ; 383 : 748 – 53 . Google Scholar Crossref Search ADS PubMed 4 Michas G , Varytimiadi A , Chasiotis I , Micha R . Maternal and child mortality in Greece . Lancet 2014 ; 383 : 691 – 293 . Google Scholar Crossref Search ADS PubMed 5 Vrachnis N , Vlachadis N , Iliodromiti Z , et al. Greece’s birth rates and the economic crisis . Lancet 2014 ; 383 : 692 – 3 . Google Scholar Crossref Search ADS PubMed 6 Hellenic Statistical Authority (ELSTAT) . Population and social conditions: Demography: Births; Demography: estimated population; Labor Market: Workforce. Available at: http://www.statistics.gr/en/statistics/pop (15 March 2016, date last accessed). 7 WHO Statistical Information Systems (WHOSIS) . Indicator definitions and metadata. Available at: http://apps.who.int/gho/data/node.wrapper.imr? x-id=1 (21 Ocotober 2017, date last accessed)]. 8 WHO . Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths . Geneva : WHO Document Production Services , 2016 . 9 WHO . Fact sheet: Preterm Birth. Available at: http://www.who.int/mediacentre/factsheets/fs363/en/ (21 October 017, date last accessed). 10 United Nations Development Programme . 2011 Human Development Report. New York: United Nations Development Program, 2011 . 11 Coviello E . DISTRATE: Stata module to compute direct standardized rates with improved confidence interval. Statistical Software Components S456708, Boston College Department of Economics, 2006 . 12 Blencowe H , Cousens S , Oestergaard MZ , et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications . Lancet 2012 ; 379 : 2162 – 72 . Google Scholar Crossref Search ADS PubMed 13 Zeitlin J , Szamotulska K , Drewniak N , et al. Preterm birth time trends in Europe: a study of 19 countries . BJOG Int J Obstet Gynaecol 2013 ; 120 : 1356 – 65 . Google Scholar Crossref Search ADS 14 Chang HH , Larson J , Blencowe H , et al. Preventing preterm births: analysis of trends and potential reductions with interventions in 39 countries with very high human development index . Lancet 2013 ; 381 : 223 – 34 . Google Scholar Crossref Search ADS PubMed 15 VanderWeele TJ , Lantos JD , Lauderdale DS . Rising preterm birth rates, 1989–2004: changing demographics or changing obstetric practice? Soc Sci Med 2012 ; 74 : 196 – 201 . Google Scholar Crossref Search ADS PubMed 16 Bernis C , Varea C , Bogin B , González-González A . Labor management and mode of delivery among Migrant and Spanish women: does the variability reflect differences in obstetric decisions according to ethnic origin? Matern Child Health J 2013 ; 17 : 918 – 27 . Google Scholar Crossref Search ADS PubMed 17 Greek Ministry of Health and WHO Regional Office for Europe . Strengthening Capacity for Universal Coverage (SCUC): Reduction of increasing trend of Caesarean sections in Greece: Available at: http://www.moh.gov.gr/articles/ministry/grafeio-typoy/press-releases/ (26 March 2017, date last accessed). 18 Reitsma MB , Fullman N , Ng M , et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015 . Lancet 2017 ; 389 : 1885 – 906 . Google Scholar Crossref Search ADS PubMed 19 Eiríksdóttir VH , Ásgeirsdóttir TL , Bjarnadóttir RI , et al. Low Birth Weight, Small for Gestational Age and Preterm Births before and after the Economic Collapse in Iceland: a Population Based Cohort Study. Young RC, editor . PLoS One 2013 ; 8 : e80499 . Google Scholar Crossref Search ADS PubMed 20 Kana M , Correia S , Peleteiro B , et al. Impact of the global financial crisis on low birth weight in Portugal: a time-trend analysis . BMJ Global Health 2017 ; 2 : e000147 . Google Scholar Crossref Search ADS PubMed 21 Varea C , Terán JM , Bernis C , et al. Is the economic crisis affecting birth outcome in Spain? Evaluation of temporal trend in underweight at birth (2003–2012) . Ann Hum Biol 2016 ; 43 : 169 – 82 . Google Scholar Crossref Search ADS PubMed 22 Carlson K . Fear itself: the effects of distressing economic news on birth outcomes . J Health Econ 2015 ; 41 : 117 – 32 . Google Scholar Crossref Search ADS PubMed 23 Kogan MD . Social causes of low birth weight . J R Soc Med 1995 ; 88 : 611 – 5 . Google Scholar PubMed 24 Racape J , Schoenborn C , Sow M , et al. Are all immigrant mothers really at risk of low birth weight and perinatal mortality? The crucial role of socio-economic status . BMC Pregnancy Childbirth 2016 ; 16 : 75 . Google Scholar Crossref Search ADS PubMed 25 Page RL . Positive pregnancy outcomes in Mexican immigrants: what can we learn? J Obstet Gynecol Neonatal Nurs 2004 ; 33 : 783 – 90 . Google Scholar Crossref Search ADS PubMed 26 Kelly Y , Panico L , Bartley M , et al. Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study . J Public Health 2008 ; 31 : 131 – 7 . Google Scholar Crossref Search ADS 27 Sdona E , Papamichail D , Ragkou E , et al. Migration status and perinatal parameters in a Greek public maternity hospital: an illustration of the “healthy immigrant effect” . J Matern Fetal Neonatal Med 2017 ; 5 . DOI: 10.1080/14767058.2017.1371131. 28 Tsimbos C , Verropoulou G . Demographic and socioeconomic determinants of low birth weight and preterm births among natives and immigrants in Greece: an analysis using nationwide vital registration micro-data . J Biosoc Sci 2011 ; 43 : 271 – 83 . Google Scholar Crossref Search ADS PubMed 29 Malamitsi-Puchner A , Voulgaris K , Sdona E , et al. Twins and socioeconomic factors: changes in the last 20 years . J Matern Fetal Neonatal Med 2017 ; 6 . DOI: 10.1080/14767058.2017.1382469. 30 Mossialos E , Allin S , Karras K , Davaki K . An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience . Eur J Public Health 2005 ; 15 : 288 – 95 . Google Scholar Crossref Search ADS PubMed 31 Flenady V , Koopmans L , Middleton P , et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis . Lancet 2011 ; 377 : 1331 – 40 . Google Scholar Crossref Search ADS PubMed 32 Neels K , Theunynck Z , Wood J . Economic recession and first births in Europe: recession-induced postponement and recuperation of fertility in 14 European countries between 1970 and 2005 . Int J Public Health 2013 ; 58 : 43 – 55 . Google Scholar Crossref Search ADS PubMed 33 Gardosi J , Madurasinghe V , Williams M , et al. Maternal and fetal risk factors for stillbirth: population based study . BMJ 2013 ; 346 : f108 . Google Scholar Crossref Search ADS PubMed 34 Luque-Fernandez MA , Franco M , Gelaye B , et al. Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007–2010: a multilevel analysis study . Eur J Epidemiol 2013 ; 28 : 991 – 9 . Google Scholar Crossref Search ADS PubMed 35 Luque-Fernández MÁ , Lone NI , Gutiérrez-Garitano I , Bueno-Cavanillas A . Stillbirth risk by maternal socio-economic status and country of origin: a population-based observational study in Spain, 2007–08 . Eur J Public Health 2012 ; 22 : 524 – 9 . Google Scholar Crossref Search ADS PubMed 36 Nybo Andersen A-M , Gundlund A , Villadsen SF . Stillbirth and congenital anomalies in migrants in Europe . Best Pract Res Clin Obstet Gynaecol 2016 ; 32 : 50 – 9 . Google Scholar Crossref Search ADS PubMed 37 Essén B , Bödker B , Sjöberg N-O , et al. Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services? BJOG Int J Obstet Gynaecol 2002 ; 109 : 677 – 682 . Google Scholar Crossref Search ADS 38 Kim D , Saada A . The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review . Int J Environ Res Public Health 2013 ; 10 : 2296 – 335 . Google Scholar Crossref Search ADS PubMed 39 ELSTAT. Single Integrated Metadata Structure (SIMS) Estimated Population and Vital Statistics: Available at: http://www.statistics.gr/en/statistics/-/publication/SPO03/- (2 April 2018, date last accessed). 40 World Bank . World Data Bank. World development indicators: Available at: http://databank.worldbank.org/data/reports.aspx? source=2&series=NY.GDP.MKTP.CD&country=GRC (17 April 2016, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Adverse effect of the financial crisis in Greece on perinatal factors

Loading next page...
 
/lp/ou_press/adverse-effect-of-the-financial-crisis-in-greece-on-perinatal-factors-SR8mqiqH7e
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
eISSN
1464-360X
D.O.I.
10.1093/eurpub/cky078
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Starting in 2008 recession affected many European countries and especially Greece. Previous studies have reported increases in low birth weight, preterm birth and stillbirth rates in Greece during early crisis. In our study we used data on births from 1980 to 2014 that allowed us to distinguish recent changes, which could possibly be attributed to the financial crisis, from long term trends, and controlled for maternal age and country of origin as potential confounders. Our study covered a longer period (up to 2014) than what has been studied before and looked separately at the effect of early and established crisis. Methods We used national vital statistics data from 1980 to 2014. We performed age standardization and calculated age standardized rates and standardized rate ratios (SRRs) for perinatal factors for three time periods (pre-crisis, early crisis and established crisis) for Greek and non-Greek women. Results We found an increase in low birth weight deliveries independent of maternal age and origin and an increased stillbirth rate in Greek women younger than 25 in early (RR = 1.42 95%CI: 1.12–1.80) and established crisis periods (RR = 1.36 95%CI: 1.07–1.72) compared with pre-crisis. Non-Greek women have also been affected, with their advantage regarding birth outcomes becoming less profound in the established crisis period (low birth weight: established crisis SRR = 0.84 95%CI: 0.82–0.87, pre-crisis SRR = 0.79 95% CI: 0.76– 0.81). Conclusions The financial crisis has possibly adversely affected perinatal factors in Greece. Our results highlight the need of appropriate public health interventions and family support policies, especially for younger people, unemployed and immigrants. Introduction Financial crises have adverse effects on population health.1 Poor economic conditions and high unemployment rates have been associated with increased infant mortality rates, greater unmet healthcare needs, increase in obstetric trauma.1 After 2008 the Greek economy has entered a phase of severe recession, characterized by high unemployment and reduction of the gross domestic product (GDP).2 From 2008 to 2014 GDP per capita was reduced by 32% (Supplementary figure A1). Consecutive austerity measures, including cuts to public health spending, have been implemented.3 The consequences of the crisis on population health and especially on perinatal factors have not been yet thoroughly investigated. A rise in infant mortality4 along with an increase in the proportion of low birth weight infants3 and stillbirth rate4 have been found in Greece after the beginning of the economic crisis. A decrease in birth rates and an increase in the mean maternal age have also been observed.5 Nevertheless, the studies that have been carried out until now cover only a short period after the beginning of the crisis, while recent changes are usually not looked at in the light of long term trends. Furthermore, possible confounding factors have not been investigated. The aim of our study was to investigate recent changes in perinatal parameters in the framework of long term trends (since 1980), in order to distinguish possible effects of the economic crisis from long-standing developments. Moreover, our study covered a longer period (up to 2014) than what has been studied before using nationwide data, and looked separately at the effect of early (2008–10) and established crisis (2011–14). Finally, in our analysis we controlled for maternal age and country of origin, which are potential confounders of the apparent association between perinatal factors and the period of the financial crisis. Methods We used national statistical data from 1980 to 2014 for live births, maternal age at birth, preterm and low birth weight deliveries, infant mortality and stillbirth rate.6 Data on births by maternal age for the year 2000 are not presented due to an error in the dataset available. Furthermore, we used national statistical data from 2004 to 2014 for the above perinatal parameters by maternal age and maternal country of origin (Greek/non-Greek)6 and data for infant mortality by infant citizenship (country) for the years that these were available (2013–15).6 Infant mortality is defined as the ratio of deaths in children under 1 year of age by the total number of live births in the same period7 and stillbirth rate as the ratio of deaths that occur before birth and after 28 completed weeks of gestation by the number of live births8; low birth weight is weight at birth <2500 g and very low birth weight <1500 g.7 Preterm birth is defined as live birth before 37 completed weeks of gestation and very preterm before 32 weeks.9 Countries were grouped using the United Nations human development index (HDI) 2014.10 All data are aggregate and were obtained from the Hellenic Statistical Authority.6 In order to study recent changes in perinatal parameters and the possible effects of the financial crisis, we defined three periods: pre-crisis (2004–07), early crisis (2008–10) and established crisis (2011–14). We performed age standardization using the direct method to compare perinatal factors in the three study periods and between Greek and non-Greek mothers. The standard population was births by maternal age in the years 2000–04 (Supplementary table A1). Standardized rate ratios (SRRs) and 95% CIs were calculated with the ‘distrate’ Stata module.11 We used Apache Open Office Calc v.4.1.1 for data process and simple calculations, and Stata 11.0 to calculate risk ratios (RRs) and 95% CIs. Results Long-term trends Low birth weight rate has been increasing since 1980 with a stabilization from 2000 to 2008 and a further increase in the early crisis period (2008–10). In the period of established crisis (2011–14), low birth weight rate is decreasing towards 2008 levels. Very low birth weight rate (<1500 g) remains constant throughout the study period (figure 1a). Figure 1 View largeDownload slide Trends in perinatal factors, Greece, 1980–2014. (a) Low birth weight and very low birth weight, percent (%) of live births. (b) Preterm births and very preterm births, percent (%) of live births. (c) Stillbirths per 1000 live births. (d) Births to women 35-years old and older, percent (%) of live births. Data source: ELSTAT6 Figure 1 View largeDownload slide Trends in perinatal factors, Greece, 1980–2014. (a) Low birth weight and very low birth weight, percent (%) of live births. (b) Preterm births and very preterm births, percent (%) of live births. (c) Stillbirths per 1000 live births. (d) Births to women 35-years old and older, percent (%) of live births. Data source: ELSTAT6 Preterm birth rate presents a radical increase since 1991, while it tends to stabilize in the established crisis period. The increase is due to births after the 32nd week of gestation, as very preterm birth rate (before 32 weeks) remain stable throughout the study period (figure 1b). Infant mortality has been constantly declining from 1980 to 2008 (historic low). From 2008 onwards (period of early and established crisis), it tends to stabilize in levels somewhat higher than 2008 (Supplementary figure A2a). After constant decrease since 1980, stillbirth rate shows an increase in the years of early crisis followed by a slight decrease thereafter, remaining, though, higher than in 2008 (figure 1c). The proportion of births to women 35-years old and older has been increasing in the last 30 years; reaching 27% of all births in 2014 (figure 1d). Births to women 35-years old and older represent 26% of total births in 2011–14, while in 2004–07 they represented 19% of total births (figure 1d). The proportion of births to non–Greek women has increased from 2004 to 2007, remained stable during early crisis and decreased in the period of established crisis (Supplementary figure A2b). Of note, the crude birth rate (births per 1000 population) in Greece has been decreasing in the years of the financial crisis (after 2008), following an 8-year period of increase, reaching historic low levels in 2014 (Supplementary figure A1). Low birth weight, preterm births and stillbirths by maternal age and origin Risk for low birth weight and preterm birth is significantly increased in early and established crisis periods compared with pre-crisis after age standardization, both in Greek and non-Greek mothers (table 1). Table 1 Comparison of age standardized rates of low birth weight, preterm birth and stillbirth by maternal origin in the three study periods n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 a ASR, age standardized rate (per 100 live births), using the direct standardization method. b SRR, age standardized rate ratio. Table 1 Comparison of age standardized rates of low birth weight, preterm birth and stillbirth by maternal origin in the three study periods n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 n ASRa SRRb 95% CI Low birth weight     Greek         Pre-crisis (2004–2007) 32 162 8.57 ref         Early crisis (2008–10) 28 194 9.30 1.08 1.07–1.10         Established crisis (2011–14) 32 380 9.20 1.07 1.06–1.09     Non-Greek         Pre-crisis (2004–07) 4679 6.75 ref         Early crisis (2008–10) 4546 7.33 1.09 1.04–1.13         Established crisis (2011–14) 4486 7.75 1.15 1.10–1.20 Preterm births     Greek         Pre-crisis (2004–07) 28 447 7.57 ref         Early crisis (2008–10) 31 252 10.14 1.34 1.32–1.36         Established crisis (2011–14) 37 811 10.56 1.39 1.37–1.42     Non-Greek         Pre-crisis (2004–07) 4038 5.86 ref         Early crisis (2008–10) 5052 8.23 1.40 1.34–1.47         Established crisis (2011–14) 5584 9.62 1.64 1.57–1.71 Stillbirths     Greek         Pre-crisis (2004–07) 1335 0.36 ref         Early crisis (2008–10) 1093 0.38 1.05 0.96–1.14         Established crisis (2011–14) 1272 0.37 1.02 0.94–1.11     Non-Greek         Pre-crisis (2004–07) 373 0.54 ref         Early crisis (2008–10) 304 0.50 0.93 0.79–1.09         Established crisis (2011–14) 334 0.57 1.06 0.91–1.24 a ASR, age standardized rate (per 100 live births), using the direct standardization method. b SRR, age standardized rate ratio. When examined by age group and citizenship, risk of low birth weight and preterm birth is significantly increased in the periods of early and established crisis in comparison to the pre-crisis period for women of both Greek and non-Greek origin and for all age groups, with the exception of low birth weight in women aged 35–39 (Supplementary table A2). Low birth weight and preterm birth rates after standardizing for age are consistently lower in women of non-Greek origin than in women from Greece and this holds for all three study periods (table 2). Table 2 Comparison of age standardized low birth weight, preterm birth and stillbirth rate, between Greek and non-Greek women, in the three study periods Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 a SRR, age standardized rate ratio. For numbers of infants and age standardized rates (see table 1). Table 2 Comparison of age standardized low birth weight, preterm birth and stillbirth rate, between Greek and non-Greek women, in the three study periods Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 Low birth weight Preterm births Stillbirths SRRa 95% CI SRRa 95% CI SRRa 95% CI Pre-crisis (2004–07) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.77 0.75–0.80 1.51 1.33–1.71 Early crisis (2008–10) Greek ref ref ref non-Greek 0.79 0.76–0.81 0.81 0.79–0.84 1.34 1.16–1.53 Established crisis (2011–14) Greek ref ref ref non-Greek 0.84 0.82–0.87 0.91 0.88–0.94 1.57 1.38–1.78 a SRR, age standardized rate ratio. For numbers of infants and age standardized rates (see table 1). Risk of stillbirth after standardizing for age doesn’t show any significant change in the early and the established crisis periods (Supplementary table 1). In contrast, risk of stillbirth in Greek women younger than 25-years old is significantly higher in the years of the financial crisis in comparison to the pre-crisis period (Table A2). Contrary to the association found for low birth weight and prematurity, risk of stillbirth is higher in mothers of non-Greek origin than in mothers from Greece, in all three study periods after standardizing for age (table 2). Stillbirth and infant mortality rates show a gradient when examined by HDI group of countries, with the risk of stillbirth being two times higher in women from countries with a medium and low HDI compared with Greek women (table 3). Table 3 RR of stillbirth and infant mortality by citizenship; countries categorized by 2014 HDI Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 a Stillbirth rate: stillbirths per 1000 live births. b Infant mortality: infant deaths per 1000 live births. Table 3 RR of stillbirth and infant mortality by citizenship; countries categorized by 2014 HDI Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 Stillbirths 2004–15 Infant mortality 2013–15 Stillbirths Stillbirth ratea RR 95% CI Infant deaths Infant mortalityb RR 95% CI Greek 3958 3.73 ref 910 3.78 ref High HDI 774 4.40 1.18 1.09–1.27 97 3.17 0.84 0.68–1.03 Medium/low HDI 145 7.65 2.04 1.73–2.41 33 9.23 2.43 1.72–3.43 a Stillbirth rate: stillbirths per 1000 live births. b Infant mortality: infant deaths per 1000 live births. Discussion An increase in low birth weight and preterm birth rates is observed during the financial crisis, in excess to a pre-existing continuing trend since 1990. The increase in low birth weight and preterm birth rates during the financial crisis cannot be explained by maternal age and origin, as it is present after age standardization for both Greek and non-Greek mothers in early crisis and established crisis periods. In contrast, the increase in stillbirths can be attributed to increased maternal age, as after age standardization there is no significant difference between pre-crisis period and early or established crisis periods. The differences in low birth weight, preterm birth and stillbirth rates between Greek and non-Greek women cannot be explained only by the difference in age distribution in the two population groups, as they are persistent and significant after age standardization. Preterm births and low birth weight The increasing trend in preterm births since 1990 is observed in other developed countries as well,12 while in many European countries in the same period the preterm birth rate for singleton births has remained stable.13 The increase in preterm birth rates has been attributed to a number of factors, like advances in foetal medicine that allow the survival of babies that would be stillborn,12 changing obstetric practice and excessive medical interventions (caesarean sections, labour induction) in the USA,14,15 Spain16 and Greece17 and the registration of extremely and very preterm births.12 Smoking is a known risk factor for preterm births and low birth weight. In the period 2005–15, smoking prevalence in women in Greece has declined by 0.6% annually,18 indicating that the observed increase in preterm birth and low birth weight rates is probably not confounded by maternal smoking. The recent global financial crisis has been associated with increases in low birth weight rates in Iceland,19 Portugal,20 Spain21 and in the USA.22 Socioeconomic factors that tend to deteriorate during a recession, like unemployment and low income, have been associated with low birth weight.23 Furthermore, socioeconomically disadvantaged women have been found to be more vulnerable to the effects of the financial crisis.19,21 We did not have information on the socioeconomic status of the mothers, to directly assess differential impact of the financial crisis on different social groups. Nevertheless, we observed an increase in low birth weight rates across most age groups during the crisis compared with the pre-crisis period, but not for women 35–39. This age group could be less exposed to adverse socioeconomic conditions, as unemployment resulting from the recession has disproportionally affected people younger than 30.6 We found that women of non-Greek origin have lower preterm birth and low birth weight rates and a lower relative risk for low birth weight and preterm births after controlling for maternal age, compared with Greek women. Better birth outcomes in migrant women, despite their lower socioeconomic status, have been observed in studies in Europe24 and the USA,25 while in the UK millennium cohort study immigrants had an increased risk for low birth weight, explained by socioeconomic factors and differences in antenatal care.26, In previous studies in Greece the advantage in favour of non-Greek women in terms of birth weight and prematurity has also been observed.27,28 Healthy immigrant effect and the adherence to healthier behaviours and diet observed in their countries of origin have been proposed as possible explanations for the observed difference in birth outcomes.28 Migrant women in Greece have a lower rate of twin deliveries in comparison to Greek women, a factor that may also contribute to the lower preterm birth and low birth weight rates observed for non-Greek women.29 Another contributing factor could be the mode of delivery, as differences in caesarean section rates between Greek and non-Greek women have been reported in previous studies.27,30 In the established crisis period, the advantage of non-Greek women regarding birth outcomes is becoming less profound (table 2). This may reflect an effect of the recession on immigrant population or it could be attributed to the fact that many immigrants have left the country since the beginning of the financial crisis (the population of non-Greek women 15–50-years old has been reduced by 11% in the years 2009–14)6 and those who stayed are possibly more similar to the native population (people who have lived in Greece for many years, second generation etc.). In a similar study in Portugal, the increase of low birth weight rates in migrant women has been interpreted as loss of the healthy immigrant effect in the context of a worse impact of the economic crisis in immigrants.20 Stillbirths—infant mortality We found evidence that older maternal age in 2008–12 is a key contributing factor to the observed increase in stillbirths during this period. After age standardization, the differences in stillbirth risk between pre-crisis period and early and established crisis periods are no longer significant. Maternal age older than 35 years has been associated with an increase of 65% in the odds of stillbirth31 in high-income countries in a meta-analysis using studies performed between 1998 and 2008 and financial crises have been associated with postponement of fertility,32 which might be a possible explanation of our findings. Of interest is the significant increase we found in the risk of stillbirth in the years of the crisis for Greek women younger than 25 years. Stillbirths are associated with poor access to healthcare and inadequate antenatal care.33 The crisis has lead to an increase in unemployment, particularly among young women6 and barriers to access to healthcare,2 which could be associated with the observed increase in stillbirths. Furthermore, younger mothers tend to have a lower educational level compared with older ones, which is an indicator of socioeconomic status; e.g. in the study period (2004–14) 33.6% of mothers aged <25 years had primary education or less compared with 7.6% of mothers 25-years old or more.6 Unemployment34 and low socioeconomic status31,35 have also been described as risk factors for stillbirth. The increased stillbirth rate observed in women of non-Greek origin shown by our data is consistent with other studies from European countries23,35–37 and has been attributed to inadequate antenatal and perinatal care and communication difficulties.36,37 Access barriers to antenatal services and communication barriers could explain the above findings of our study. Moreover, we observed a clear gradient in stillbirth risk by HDI group of countries of origin. Other studies have shown that women of African origin are the most disadvantaged in terms of stillbirth,23,35,37 but the factors driving this difference in the case of Greece need to be investigated. Infant mortality is an indicator associated with living conditions and socioeconomic status.38 We found higher infant mortality in women originating from countries with medium and low HDI, probably reflecting that these populations are the most disadvantaged among immigrants. Conclusions In our study we used data on births from 1980 to 2014 that allowed us to distinguish recent changes, which could possibly be attributed to the financial crisis, from long term trends. Moreover, our study covered a longer period (up to 2014) than what has been studied before using nationwide data, and looked separately at the effect of early and established crisis. Finally, in our analysis we controlled for maternal age and country of origin, which are potential confounders of the apparent association between perinatal factors and the period of the financial crisis. An important limitation of our study is the use of routinely collected aggregate data on births and our investigation was restricted to the impact of the factors for which data was available. Although in our study we used information regarding an extended period of time, the data used are comparable. Complete registration of births and stillbirths has been well established in Greece in the whole study period, and national data on the variables we used (maternal age, birth weight, gestational age) have been consistently collected.39 In conclusion, we showed that there is an increase in low birth weight and preterm deliveries associated with the financial crisis in Greece, that cannot be explained by maternal age and country of origin, while the effect of the crisis on stillbirths can be explained by changes in the distribution of these parameters, with the notable exception of the increase in stillbirth rate among Greek women younger than 25-years old. We also showed that rates of low birth weight and preterm deliveries are more favourable in non-Greek women, an advantage that became less profound in the period of established crisis. Public health policies ensuring access to adequate perinatal care for all women, including immigrants, unemployed and uninsured, and targeted social support interventions for women of reproductive age and young couples are needed in order to support families and alleviate the negative effects of the financial recession. These measures could include: increased funding of public prenatal and maternity care; the reintroduction of family benefits for all employees (cut with the austerity measures in 2012); policies facilitating the entry into the labour market for younger people; the employment of intercultural mediators which could help immigrants overcome communication difficulties. Analytical studies investigating more risk factors, including individual-level socioeconomic status indicators, are needed in order to establish causal associations and pathways between the recession and adverse effects on perinatal factors, and determine the factors lying behind the differences in birth outcomes between women of Greek and non-Greek origin, in order to design and implement more targeted interventions. Conflicts of interest: None declared. Acknowledgements The authors would like to thank the Hellenic Statistical Authority (ELSTAT) for providing the data. Key points The financial crisis in Greece contributed to an increase in low birth weight and preterm deliveries independently of maternal age and country of origin. The effect of the financial crisis on stillbirths can be explained by changes in maternal age and origin distribution, with the notable exception of the increase in stillbirth rate among Greek women younger than 25-years old. Rates of low birth weight and preterm deliveries are more favourable in non-Greek women, an advantage that became less profound in the period of established crisis. Our results highlight the need for appropriate public health interventions and family support policies, especially for younger people, unemployed and immigrants. References 1 van Gool K , Pearson M . Health, Austerity and Economic Crisis: Assessing the Short-term Impact in OECD countries. OECD Health Working Papers, OECD Publishing; 2014 . Report No.: 76 Available at: http://dx.doi.org/10.1787/5jxx71lt1zg6-en (23 March 2016, date last accessed) 2 Zavras D , Zavras AI , Kyriopoulos I-I , Kyriopoulos J . Economic crisis, austerity and unmet healthcare needs: the case of Greece . BMC Health Serv Res 2016 ; 16 : 309 . Google Scholar Crossref Search ADS PubMed 3 Kentikelenis A , Karanikolos M , Reeves A , et al. Greece’s health crisis: from austerity to denialism . Lancet 2014 ; 383 : 748 – 53 . Google Scholar Crossref Search ADS PubMed 4 Michas G , Varytimiadi A , Chasiotis I , Micha R . Maternal and child mortality in Greece . Lancet 2014 ; 383 : 691 – 293 . Google Scholar Crossref Search ADS PubMed 5 Vrachnis N , Vlachadis N , Iliodromiti Z , et al. Greece’s birth rates and the economic crisis . Lancet 2014 ; 383 : 692 – 3 . Google Scholar Crossref Search ADS PubMed 6 Hellenic Statistical Authority (ELSTAT) . Population and social conditions: Demography: Births; Demography: estimated population; Labor Market: Workforce. Available at: http://www.statistics.gr/en/statistics/pop (15 March 2016, date last accessed). 7 WHO Statistical Information Systems (WHOSIS) . Indicator definitions and metadata. Available at: http://apps.who.int/gho/data/node.wrapper.imr? x-id=1 (21 Ocotober 2017, date last accessed)]. 8 WHO . Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths . Geneva : WHO Document Production Services , 2016 . 9 WHO . Fact sheet: Preterm Birth. Available at: http://www.who.int/mediacentre/factsheets/fs363/en/ (21 October 017, date last accessed). 10 United Nations Development Programme . 2011 Human Development Report. New York: United Nations Development Program, 2011 . 11 Coviello E . DISTRATE: Stata module to compute direct standardized rates with improved confidence interval. Statistical Software Components S456708, Boston College Department of Economics, 2006 . 12 Blencowe H , Cousens S , Oestergaard MZ , et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications . Lancet 2012 ; 379 : 2162 – 72 . Google Scholar Crossref Search ADS PubMed 13 Zeitlin J , Szamotulska K , Drewniak N , et al. Preterm birth time trends in Europe: a study of 19 countries . BJOG Int J Obstet Gynaecol 2013 ; 120 : 1356 – 65 . Google Scholar Crossref Search ADS 14 Chang HH , Larson J , Blencowe H , et al. Preventing preterm births: analysis of trends and potential reductions with interventions in 39 countries with very high human development index . Lancet 2013 ; 381 : 223 – 34 . Google Scholar Crossref Search ADS PubMed 15 VanderWeele TJ , Lantos JD , Lauderdale DS . Rising preterm birth rates, 1989–2004: changing demographics or changing obstetric practice? Soc Sci Med 2012 ; 74 : 196 – 201 . Google Scholar Crossref Search ADS PubMed 16 Bernis C , Varea C , Bogin B , González-González A . Labor management and mode of delivery among Migrant and Spanish women: does the variability reflect differences in obstetric decisions according to ethnic origin? Matern Child Health J 2013 ; 17 : 918 – 27 . Google Scholar Crossref Search ADS PubMed 17 Greek Ministry of Health and WHO Regional Office for Europe . Strengthening Capacity for Universal Coverage (SCUC): Reduction of increasing trend of Caesarean sections in Greece: Available at: http://www.moh.gov.gr/articles/ministry/grafeio-typoy/press-releases/ (26 March 2017, date last accessed). 18 Reitsma MB , Fullman N , Ng M , et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015 . Lancet 2017 ; 389 : 1885 – 906 . Google Scholar Crossref Search ADS PubMed 19 Eiríksdóttir VH , Ásgeirsdóttir TL , Bjarnadóttir RI , et al. Low Birth Weight, Small for Gestational Age and Preterm Births before and after the Economic Collapse in Iceland: a Population Based Cohort Study. Young RC, editor . PLoS One 2013 ; 8 : e80499 . Google Scholar Crossref Search ADS PubMed 20 Kana M , Correia S , Peleteiro B , et al. Impact of the global financial crisis on low birth weight in Portugal: a time-trend analysis . BMJ Global Health 2017 ; 2 : e000147 . Google Scholar Crossref Search ADS PubMed 21 Varea C , Terán JM , Bernis C , et al. Is the economic crisis affecting birth outcome in Spain? Evaluation of temporal trend in underweight at birth (2003–2012) . Ann Hum Biol 2016 ; 43 : 169 – 82 . Google Scholar Crossref Search ADS PubMed 22 Carlson K . Fear itself: the effects of distressing economic news on birth outcomes . J Health Econ 2015 ; 41 : 117 – 32 . Google Scholar Crossref Search ADS PubMed 23 Kogan MD . Social causes of low birth weight . J R Soc Med 1995 ; 88 : 611 – 5 . Google Scholar PubMed 24 Racape J , Schoenborn C , Sow M , et al. Are all immigrant mothers really at risk of low birth weight and perinatal mortality? The crucial role of socio-economic status . BMC Pregnancy Childbirth 2016 ; 16 : 75 . Google Scholar Crossref Search ADS PubMed 25 Page RL . Positive pregnancy outcomes in Mexican immigrants: what can we learn? J Obstet Gynecol Neonatal Nurs 2004 ; 33 : 783 – 90 . Google Scholar Crossref Search ADS PubMed 26 Kelly Y , Panico L , Bartley M , et al. Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study . J Public Health 2008 ; 31 : 131 – 7 . Google Scholar Crossref Search ADS 27 Sdona E , Papamichail D , Ragkou E , et al. Migration status and perinatal parameters in a Greek public maternity hospital: an illustration of the “healthy immigrant effect” . J Matern Fetal Neonatal Med 2017 ; 5 . DOI: 10.1080/14767058.2017.1371131. 28 Tsimbos C , Verropoulou G . Demographic and socioeconomic determinants of low birth weight and preterm births among natives and immigrants in Greece: an analysis using nationwide vital registration micro-data . J Biosoc Sci 2011 ; 43 : 271 – 83 . Google Scholar Crossref Search ADS PubMed 29 Malamitsi-Puchner A , Voulgaris K , Sdona E , et al. Twins and socioeconomic factors: changes in the last 20 years . J Matern Fetal Neonatal Med 2017 ; 6 . DOI: 10.1080/14767058.2017.1382469. 30 Mossialos E , Allin S , Karras K , Davaki K . An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience . Eur J Public Health 2005 ; 15 : 288 – 95 . Google Scholar Crossref Search ADS PubMed 31 Flenady V , Koopmans L , Middleton P , et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis . Lancet 2011 ; 377 : 1331 – 40 . Google Scholar Crossref Search ADS PubMed 32 Neels K , Theunynck Z , Wood J . Economic recession and first births in Europe: recession-induced postponement and recuperation of fertility in 14 European countries between 1970 and 2005 . Int J Public Health 2013 ; 58 : 43 – 55 . Google Scholar Crossref Search ADS PubMed 33 Gardosi J , Madurasinghe V , Williams M , et al. Maternal and fetal risk factors for stillbirth: population based study . BMJ 2013 ; 346 : f108 . Google Scholar Crossref Search ADS PubMed 34 Luque-Fernandez MA , Franco M , Gelaye B , et al. Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007–2010: a multilevel analysis study . Eur J Epidemiol 2013 ; 28 : 991 – 9 . Google Scholar Crossref Search ADS PubMed 35 Luque-Fernández MÁ , Lone NI , Gutiérrez-Garitano I , Bueno-Cavanillas A . Stillbirth risk by maternal socio-economic status and country of origin: a population-based observational study in Spain, 2007–08 . Eur J Public Health 2012 ; 22 : 524 – 9 . Google Scholar Crossref Search ADS PubMed 36 Nybo Andersen A-M , Gundlund A , Villadsen SF . Stillbirth and congenital anomalies in migrants in Europe . Best Pract Res Clin Obstet Gynaecol 2016 ; 32 : 50 – 9 . Google Scholar Crossref Search ADS PubMed 37 Essén B , Bödker B , Sjöberg N-O , et al. Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services? BJOG Int J Obstet Gynaecol 2002 ; 109 : 677 – 682 . Google Scholar Crossref Search ADS 38 Kim D , Saada A . The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review . Int J Environ Res Public Health 2013 ; 10 : 2296 – 335 . Google Scholar Crossref Search ADS PubMed 39 ELSTAT. Single Integrated Metadata Structure (SIMS) Estimated Population and Vital Statistics: Available at: http://www.statistics.gr/en/statistics/-/publication/SPO03/- (2 April 2018, date last accessed). 40 World Bank . World Data Bank. World development indicators: Available at: http://databank.worldbank.org/data/reports.aspx? source=2&series=NY.GDP.MKTP.CD&country=GRC (17 April 2016, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

The European Journal of Public HealthOxford University Press

Published: Dec 1, 2018

References

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off